Every finding on record at St Luke's Helen G Nassif Transitional Care Center

Based on staff and resident interviews, clinical record review, and facility policy review, the facility failed to ensure a resident was treated in a dignified manner for 1 of 5 residents reviewed (Residents #3). The facility reported a census of 41 residents.Findings include: The Minimum Data Set (MDS) dated [DATE] identified Resident #3 was cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15, and had the following diagnoses: Chronic diastolic (congestive) heart failure, diabetes mellitus and morbid obesity. The MDS also identified the resident required substantial staff assistance for chair/bed to chair transfer and to walk ten feet.The Care Plan dated 2/23/2026 identified the resident at risk for falling related to impaired mobility, weakness, debility, GI (gastrointestinal) infection, obesity, and pain. The Care Plan goal reflected Resident #3 would transfer and ambulate with assistance while minimizing the risk of falls. The intervention initiated 3/4/26 revealed, Ambulate resident with assist of 1 with wheelchair, walker in room and to nurses station and to dining room. During an interview on 3/2/2026 at approximately 3:45 PM, Resident #3 advised she had one Certified Medication Assistant (CMA) identified as Staff A, that had made very rude comments to her. Resident #3 shared on 2/16/26 she felt weak and asked Staff A to assist and push their wheelchair to the dining room and the staff member responded you need to do it yourself. When the resident told the worker they couldn't they were too weak right now Staff A responded can't push [resident], [resident] are too heavy for me to push. Resident #3 advised she felt humiliated. Resident #3 described another incident in which a different staff member was assisting her and Staff A walked by and said, you know she can do that herself, and the resident responded, No that is not in [resident's] plan. Staff A reportedly responded back, you need to mind your own business [Staff A] wasn't talking to [Resident], [Staff A] was talking to staff. Resident #3 shared she felt very disrespected by Staff A. Review of a typed document provided by facility revealed the Director of Nursing and Assistant Director of Nursing (ADON) had spoken with the resident on 2/23/26. The document revealed the resident had stated that a staff member had spit in the garbage can in the dining room and it was beside her while she was eating. She lost her appetite and pushed her food away. On 3/04/2026 at 12:26 PM, Staff C, Certified Nursing Assistant (CNA) reported during a shift change meeting she heard Staff A tell one of the nurses she had told Resident #3 they were too heavy for her to push and that she probably should not have said that and she wanted to apologize to the resident. Review disciplinary action taken by the facility with Staff A revealed, in part, the following: A 2/23/26 Disciplinary Report Form revealed, in part, Tone when speaking to a resident and felt it was clashing, demanding .Spit in a garbage can.On 03/05/26 at 1:50 PM, Staff A was queried, and acknowledged did say the resident was too heavy to push, acknowledged shouldn't have said that, explained tried to apologize, and the resident didn't want to hear it. Staff A explained she tried to push the residents to do what they could to help themselves. That is why most of them are here. To get better and return home. It's not a personal thing but Staff A explained thought this resident and [Staff A] just rubbed each other the wrong way. Per Staff A, the resident thought [Staff A] was being rude or mean and in their own way, Staff A explained tried to be assertive and push her to get better. Staff A explained the incident when they spit in the garbage, that was unfortunate. Staff A explained just went to the nearest garbage to expel it and didn't really pay that much attention, put their face down to the garbage and covered it with their hand as it spit. Per Staff A, was not a disrespectful thing and was not something could control. Staff A advised she did not ever remember telling the resident that something was none of her business. On 3/05/2026 at 2:14 PM, an interview was held with the Director of Nursing (DON). She advised was aware of a clash of personalities between Resident #3 and Staff A. The DON advised being aware of several incidents between the resident and staff member. The DON advised, in part, Staff A had now been told she had to make it to somewhere private or to the staff bathroom before spitting. The DON advised the way Staff A can come across can be misconstrued as being harsh or demanding. Staff A had been talked to and advised to work on her tone and presentation. The DON advised it was her expectation that staff are professional, kind and upbeat and that they follow the facility policies and procedures.Review of the undated facility document titled, [Facility Name] admission Agreement : Resident [NAME] of Rights revealed, A. Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. 1. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment, that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

Based on clinical record review, policy review, and resident and staff interviews the facility failed to follow physician orders by not giving medications within 1 hour before to 1 hour after the ordered time for 3 of 3 residents reviewed (Residents #6, #21, and #27). The facility reported a census of 41 residents.Findings include:1.Resident #6's admission record documented an admission date of 1/29/26 and a discharge date of 2/27/26. The Order Recap Report included medications to be given up to 2 times per day. The Medication Admin Audit Report for February revealed medications not given within the 2 hour time frame it was to be given (1 hour before to 1 hour after the ordered time) on 4 separate days. The clinical record lacked documentation of provider notification.2. Resident #21's admission record documented an admission date of 2/19/26 and a discharge date of 3/4/26. The Order Recap Report included medications to be given up to 4 times per day. The Medication Admin Audit Report for February and March revealed medications not given within the 2 hour time frame it was to be given (1 hour before to 1 hour after) on 10 separate days. The clinical record lacked documentation of provider notification.3. Resident #27's admission record documented an admission date of 2/20/26. The resident had not been discharged . The Order Recap Summary Report included medications to be given up to 3 times per day. The Medication Admin Report for February and March revealed medications not given within the 2 hour time frame it was to be given (1 hour before and 1 hour after) on 7 separate days. The clinical record lacked documentation of provider notification. During an interview on 3/5/26 at 9:57 AM, the resident reported his medications could be late. He reported his insulin was given around the time he ate, but his pills could be more variable.During an interview on 3/5/26 at 1:16 PM, the Director of Nursing (DON) explained staff have 1 hour before and 1 hour after the time the medications are ordered to give the medications. If the medications are early or late for any reason, the provider should be notified. She would expect staff to follow the policy.The facility policy titled Medication Administration last revised on 6/30/23 directed staff to give the medications one hour prior to one hour after the scheduled administration time. If the administration occurs outside of these time frames, physician notification is required.

Based on observations, clinical record review, staff interview, and facility policy review the facility failed to toilet 1 out of 1 resident reviewed (Resident #9). The facility reported a census of 32 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE], listed diagnoses of Parkinson's disease, dementia, adult failure to thrive, and Schizophrenia. The Brief Interview for Mental Status (BIMS) reflected short-term and long-term memory problems and severely impaired daily decision making skills. The MDS identified Resident #9 frequently incontinent of bowel and bladder. The MDS reflected Resident #9 required substantial/maximal assistance with toileting and dependent with toileting hygiene. The Care Plan for Resident #9 dated 05/31/2024, directed staff to provide toileting assistance before and after meals, at bedtime, and as needed. Provide incontinence care after each incontinent episode. On 1/28/25 at 12:35 PM Staff A, Certified Nurse Aid (CNA) pushed Resident #9 from the dining room (DR) to the lounge area. Staff A and Staff B, CNA transferred Resident #9 to the recliner next to the window, they covered him with a blanket and elevated his feet. Resident #9 called out help help as they transferred him to the recliner. On 1/28/25 at 12:38 PM, Resident #9 appeared to void in his chair, liquid poured out of the left side of the chair onto the carpet under him. He put the blanket over his head and moved himself in the chair some. On 1/28/25 at 1:00 PM, Activity staff went to Resident #9 and offered him popcorn. Resident #9 slept through the question. On 1/28/25 at 01:46 PM, Activity staff delivered a bag of popcorn to Resident #9, he sat up and ate the snack. On 1/28/25 at 1:52 PM, the Activity staff went to him and asked if he wanted more popcorn. The Assistant Director of Nursing (ADON) and the MDS Coordinator stood in the corner of the room for a few minutes. Resident #9 started to cough and the Activity staff offered him a drink. On 1/28/25 at 3:00 PM, Resident #9 remained seated in the recliner chair in the lounge from 12:35 PM where at 12:38 he appeared to have urinated. On 1/28/25 at 3:20 PM, the carpet under Resident # 9 looked a darker color than the rest of the carpet in the area. On 1/28/25 at 3:24 PM, the ADON reported staff are expected to toilet residents before meals, after meals, at bedtime, as needed, and every 2 hours at night. On 1/28/25 at 3:58 PM, the Registered Nurse Consultant (RNC) reported the facility failed to have a policy directing how and when to toilet residents. She said the staff are expected to follow the Care Plan.

Based on clinical record review, policy review, family and resident interviews, the facility failed to address the Baseline Care Plan with the resident or the resident's legal representative for 1 of 1 resident's sampled (Resident #1). The facility identified a census of 28 residents. Findings include: The Electronic Medical Record (EMR) Census documented Resident #1 admitted to the facility on [DATE]. The Baseline Care Plan documented Staff A, Minimum Data Set (MDS) Coordinator completed the Baseline Care Plan on 2/23/24. The Resident and Resident Representative Signatures Lines were blank on the Care Plan form and there were no notations stating the Baseline Care Plan had been reviewed with the resident or family. Resident #1's MDS assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 10 out of 15 indicating a moderate cognitive loss. A review of the Progress Notes from 2/22/23 to 3/05/24 lacked documentation the resident or the resident's representative received a copy of the Baseline Care Plan or that the facility had reviewed the Baseline Care Plan with them. An interview with a family member on 4/16/24 at 4:40 PM reported she never received a copy of the Baseline Care Plan nor was the Baseline Care Plan discussed with her. During an interview on 4/18/24 at 9:18 AM Staff A, MDS Coordinator explained she completes the Baseline Care Plan electronically on the computer. The facility had been using a paper form prior to her taking the position. She does not do anything with the Care Conference and does not attend the Care Conferences. She believes that when the Care Conference is held, a copy of the Baseline Care Plan is given to the resident or legal representative to sign by the Director of Nursing (DON). On 9/18/24 at 9:40 AM Staff B, MDS Coordinator verbalized when a resident admitted to the facility she would complete the Baseline Care Plan the day of admission or the next day using a paper form. She then gave the Baseline Care Plan to the DON. She never attended the Care Conferences. The DON would take care of taking the Baseline Care Plan to the Care Conference and go over it with the resident or the family and have one of them sign to acknowledge that the Care Plan had been reviewed with them. After the Baseline Care Plan was signed, the DON would give the Care Plan back to her to put in a binder at the nurse's station. Their practice was to have the resident or the family sign to acknowledge that the Baseline Care Plan had been reviewed with them. If the resident couldn't sign the Baseline Care Plan, they would have a family member sign it or go over the Baseline Care Plan by phone with the family, then the DON would document she went over the Baseline Care Plan with the family on the form. During an interview on 4/18/24 at 10:43 AM the DON reported the Baseline Care Plan starts on a paper form the day of admission. If the resident has a lower BIMS score, then they talk to the family either at the Care Conference or they call the family to review the Baseline Care Plan. She expects the Baseline Care Plan to be gone over with the resident if capable. If not, then the Baseline Care Plan should be reviewed with the family. She verbalized the review should be completed and documented either on the Baseline Care Plan or in the EMR. On 4/18/24 at 11:53 AM the DON reported she had reviewed the documentation and could not find where they had gone over the actual Baseline Care Plan with the resident or the family and that should have been done. The Baseline Care Plan Policy revised 5/15/2019 directed a written summary of the Baseline Care Plan must be provided to the resident and their representative in a manner they can understand. The documentation must be present in the medical record stating the Care Plan was shared with the resident and their representative.

Based on observation, staff interview, and facility policy review, the facility failed to label and date food items when opened to reduce the risk of contamination and food-borne illness. The facility reported a census of 31 residents. Findings Include: On 1/16/24 at 10:08 AM, during the initial tour of the facility kitchen revealed the following food items not labeled or dated when opened: a. A bag of frozen baby baker potatoes. b. A bag of frozen mixed vegetables. c. A bag of frozen fajita blend vegetables. d. A bag of frozen cascade blend vegetables. e. A bag of frozen pasta. f. A bag of frozen garlic bread. g. A bag of elbow macaroni noodles. h. A bag of egg noodles. i. A bag of spaghetti noodles. j. A bag of long grain rice. k. A bag of brown sugar. In an interview on 1/16/24 at 1:30 PM, the Dietary Supervisor stated it was the expectation when staff open any food item, they are to label and date anything that is not completely used and to be saved for later. The Dietary Supervisor stated she had posted signs around the kitchen area to remind staff in the past but it continued to be an issue. The facility provided policy titled Food Storage dated October 2023, the policy directed Dietary Staff, all opened packages or containers must be covered and accurately labeled. It further documented leftover food was to be stored in covered containers or wrapped carefully and securely. Each item was to be clearly labeled and dated before being refrigerated.

Based on clinical record review, facility document review and staff interview, the facility failed to comply with all applicable Federal Regulations regarding Medicare requirements governing billing practices for 2 of 3 residents reviewed for Liability and Appeal notices (Resident #183 and #184). The facility identified a census of 31 residents. Findings Include: 1. Review of facility documentation for Resident #183 revealed the resident started Skilled Services 7/17/23 and the last covered day of Part A Services was 7/28/23. The facility Administrator could not provide a signed form to verify the resident received notification of the Medicare options or their appeal rights. 2. Review of facility documentation for Resident #184 revealed the resident started skilled services 8/25/23 and the last covered day of Part A services was 9/5/23. A facility form titled Notice of Medicare Non-coverage was provided and signed by the resident but not dated to indicate when the resident was notified of Medicare options or their appeal rights. In an interview on 1/17/24 at 4:35 PM, the Administrator stated it was the expectation the Social Worker complete the needed paperwork to notify residents of therapy services ending in a timely manner. It was the expectation the Social Worker have the Office Manager complete the paperwork in her absence and the staff person scanning the paperwork into the system was to double check to ensure the paperwork was filled out completely and correctly.

Based on observations, staff interviews and facility policy review the facility failed to have the residents' Baseline Care Plans available for staff to review for 4 out of 4 resident reviewed (Resident #76, #77, #78, and #79). The facility reported a census of 30 residents. Findings Include: 1. The Minimum Data Set Assessment (MDS) for Resident # 76 dated 11/3/22, listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS reflected the residents Brief Interview for Mental Status (BIMS) score as 11 out of 15 (moderately impaired) and the resident lacked wandering behaviors in the look back period. Resident #76's Baseline Care Plan dated 10/28/22, failed to reflect the residents wandering. The Alert Note dated 11/08/22 at 9:01 AM, read Resident #76 wandering, patient walking in hallway due to getting tired of being isolated, related to Coronavirus Disease (COVID-19). She is out of her room tomorrow after isolation 10 days for (+) COVID. Patient easily redirected back to room. On 11/08/22 at 3:55 PM, Staff K Registered Nurse (RN) reported the Care Plans are in the in the computer chart, they are normally in the day of or the next day. Staff K attempted to locate the Care Plan and confirmed she failed to know where the Care Plans were. Staff K stated Resident #76 wanders some in the evening. 2. The Admission Record for Resident #77 dated 11/10/22, listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Baseline Care Plan for Resident #77 dated 11/3/22, directed assist of 1 staff for toileting and identified the urinary catheter and the ostomy. On 11/10/22 at 8:11 AM, Staff A, Certified Nurse Aid (CNA) offered the resident to use of the bathroom, Resident #77 has catheter and ostomy. Resident #77 reported no need the bathroom. 3. The Admission Record for for Resident #78 dated 11/9/22, listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Baseline Care Plan for Resident #78 dated 11/2/22, addressed the residents use of antibiotic, insulin, anticoagulant and diuretics. 4. The Minimum Data Set Assessment (MDS) for Resident #79 dated 11/2/22, listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS read the Brief Interview for Mental Status (BIMS) score as 11 out of 15 (moderately impaired). The MDS reflected Resident # 79 with wandering behavior 4-6 days out of the 7 in the reference period. The Care Plan for Resident # 79 dated 11/8/22, failed to reflect the use of the anti-psychotic medication and failed to address wandering. On 11/10/22 at 1:16 PM, the Director of Nursing (DON) reported her expectation is the Nursing department have access to the Care Plans. The facility provided a policy titled Comprehensive Care Plan dated 7/18/22, directed care, treatment and services shall be planned to ensure that they are individualized to the resident's needs. The facility shall provide an individualized, interdisciplinary Plan of Care for all residents that shall be appropriate to the resident's needs, strengths, results of diagnostic testing, limitations and goals. 5. On 11/9/22 at 7:20 AM, an interview was completed with Staff J, Registered Nurse/ MDS Coordinator. When asked about individual resident Care Plans, Staff J stated the facility Care Plan process had been to scan resident Care Plans into the Electronic Health Record (EHR) on day 14. When asked further about resident Care Plan needs between day 1 and day 14 and the facility process, Staff J stated the staff had to access the Baseline Care Plan located within the MDS office. Further interview revealed the individual resident Care Plans for day 1 through day 14 had been placed in a 3-ring binder. Staff had access to the MDS office during daytime hours. For Baseline Care Plan access after 6:00 PM, the staff had to get a key from the nurse's key ring to access the office. Staff J further stated there are Basic Care Plan Signs in patients' rooms with transfer information for Certified Nurse Aides (CNA) and the Nurses had access to provide resident care by utilizing the EHR, Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/9/22 at 9:05 AM, an interview was completed with Staff H, Agency Certified Nurse Aide (CNA). Staff H revealed she had not known how to locate Baseline Care Plan information on residents. Staff H stated she had worked shifts for one year at the facility, and when asked how she knew how to provide individual care for a residents, she stated the nurse would have been a resource. Staff H further stated there had been some Care Plan information on the resident's whiteboards in the room. An interview had been completed on 11/9/22 at 9:07 AM, with Staff G CNA. When asked where resident's individual Baseline Care Plan documentation could be located, Staff G stated she did not have knowledge of where to locate resident Baseline Care Plan information. Staff G further stated the resident's transfer information was on the whiteboard in their room. On 11/9/22 at 9:15 AM, an interview completed with Staff D, CNA who stated she had worked at the facility for 1.5 years. Staff D stated she was unaware where or how to locate Baseline Care Plan information on residents. Staff D further stated transfer information on residents was located on the resident's whiteboard in the resident's room.

Based on observation, staff interview, record review and facility policy review, the facility failed to adequately count narcotics and provide secure storage for medications during 1 out of 3 observations of a Narcotic Count between two shifts. The facility reported 9 residents with Doctor Orders for narcotic medications. The facility reported a census of 30 residents. Findings Include: According to the Minimum Data Set (MDS) assessment dated [DATE] for Resident #17 shown diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified Resident #17 scored a 9 out of 15 on the Brief Interview for Mental Status (BIMS), indicating the resident had severe cognitive impairments. The MDS documented the resident needed extensive of two staff for transfers, bed mobility, toileting and personal hygiene. During an observation 11/08/22 at 2:10 PM, Staff M, Licensed Practical Nurse, (LPN) who worked the day shift and Staff L, Registered Nurse (RN) who arrived to work the evening shift. The two completed a Narcotic Count for change of shift without discrepancies in the count. Staff L verified contents of the Medication Card and matched the number of medications with documentation on the Narcotic Sheet for each medication. Staff M, LPN stated she had counted and signed out the Medication Count earlier. Staff M, LPN stood next to the cart while Staff L, RN counted. They failed to verify by looking at both the card and the book together. Review of the Controlled Substance Shift Count and Usage Record revealed a discrepancy for Resident #17 [MEDICATION(S)] 5 milligram (mg)/325 mg medication on 11/1/22. During an interview on 11/8/22 at 4:28 PM, Staff L, stated the count is done with Nurse who is on the shift and the Nurse who is coming on shift, we both count together and if there is a difference on the shift we notify the Director of Nursing (DON). Sometimes people will say I already counted and have me try to count by myself but I tell them no because they encourage staff to count together. He stated sometimes to save time Nursing Staff may sign out ahead but you have to make sure another Nurse is checking with you. During an interview on 11/09/22 at 8:47 AM, Staff N, RN Agency Nurse stated on the morning of 11/1/22, the day the discrepancy was noted she counted with the Nurse from night shift. She stated one of us stood at the book and one at the drawer, she can't recall which role she did. One looked at the book and signed as the other one counted in the drawer. She stated we did not see the book or the card together, one person signed the book and one person looked at the card. In the afternoon I counted with another Nurse and there was a discrepancy so I showed the Day Shift Nurse. When Staff N first came on for her shift, she noted the narcotic book sitting on top the Medication Cart and the keys were tucked inside the book. During an interview on 11/9/22 at 1:42 PM, Staff M, LPN stated she has come to work in the morning and the Medication Cart keys will be in the Narcotic Book on the Medication Cart and the Nurse will be sitting at the Nurse's Station. There is only one Nurse here at night and has to carry three sets of keys. Yesterday when Staff L and I were doing the narcotic count I felt he was showing the Medication Cards to me. Staff M stated when asked if she could see them, stated yes and no. She stated she will do a count ahead of the next Nurse and sign and then the Nurse coming on will do a count and verify it is correct. During an interview on 11/10/22 at 12:58 PM, the Director of Nursing (DON) stated Staff L, RN told her the concern about staff doing the Narcotic Count by themselves before the other Nurse arrived about a week before the incident with the missing medication. The DON stated would expect both Nurses to look at the card and the book at the same time and sign off that the count is accurate for each medication in the Narcotic Count. The keys should be kept by the Nurses at all times is the expectation. The facility provided a policy titled Administration of Controlled Medications revised 6/28/22 the policy directed staff at each shift change, a physical inventory of all schedule II medications (narcotics) is conducted by two licensed Nurses and is documented on an Audit Record.

Based on clinical record review, facility policy review and staff interviews the facility failed to implement Advance Directives, and establish mechanisms for documenting and communicating resident choices in regards to Code Status (To have Cardiopulmonary Resuscitation or not) to the interdisciplinary team and to staff responsible for the resident's care for 1 of 16 residents reviewed (#179). The resident census was 30. Findings Include: On 11/7/22, review of Resident #179's physical chart showed no documentation of an Advance Directive had been placed in the Residents' chart. During an interview on 11/9/22 at 7:00 AM, Staff B, the Director of Nursing (DON) was asked where to locate a resident's Advance Directive document and stated if a resident had completed an Advance Directive then a form would be in the Residents' paper chart at the Nurses Desk located at the end of the hallway. When Staff B was asked how facility staff would know how to provide resident care regarding code status she explained the Advance Directive form in the physical chart would direct the resident care. On 11/9/22 at 7:05 AM, a review of Resident #179 physical chart showed the chart remained without Advance Directive documentation. On 11/9/22 at 7:10 AM, an interview was completed with Staff F, Registered Nurse (RN). When Staff F was asked where to locate a resident's Advance Directive documents,she stated being unsure due to never reviewing residents' paper charts. When Staff F was asked about Advance Directives for Resident #179 and how to provide care chosen by the resident; Staff F explained the facility's electronic Point Click Care (PCC) Program contained an Admission Face Sheet document that included Advance Directives. Staff F accessed Resident #179 electronic health record (EHR) face sheet which had showed an Admission Face Sheet for Resident #179. The form had been reviewed and failed to provide documentation of Advance Directive code status. On 11/9/22 at 8:15 AM Staff B, DON was asked to locate Resident #179 Advance Directives form for review. On 11/9/22 at 8:20 AM, Staff B found the Advance Directive form for Resident #179 for review. Staff B further stated the Advance Directive form had been removed from Resident #179 chart for the Provider signature completion on 11/8/22. Review of Resident #179's Advance Directive form showed the form had been signed by Resident #179 on 10/28/22 and then had been signed on 11/8/22 by the Provider, Staff I, Advanced Registered Nurse Practitioner (ARNP). Staff B further stated Resident #179 Advance Directive form had been removed from the chart for Staff I's signature on 11/8/22. Staff B further stated the Advance Directive form had not been returned to the resident chart afterward. When asked how evening or night shift staff would know Resident #179's Advance Directive status the DON then stated it had been a mistake to not return the form to the resident chart yesterday (11/8). Staff B, further stated staff would have to call Administration if a resident code status had needed clarification. During an interview on 11/9/22 at 9:07 AM, Staff G, Certified Nurse Aide (CNA) stated a resident's Advance Directive intervention could be located on a whiteboard in the resident room. On 11/9/22 at 9:15 AM, an interview completed with Staff D, CNA. When asked about Advance Directive intervention for a resident, Staff G stated I am honestly not sure where to find Advance Directives and further stated a folder may have been available at the Nurse's Desk. On 11/9/22 at 9:36 AM, Resident #179 observed in her room during wound care. Resident #179's Code Status/ Advance Directive not observed on the whiteboard nor located on the paper Care Form.

Based on record review, staff and family interviews, and policy review, the facility failed to notify the Power of Attorney (POA) of a cognitively impaired resident of a medication error and missing medication for 1 out of 1 residents reviewed (Resident #17). The facility reported a census of 30 residents. : Findings Include: According to the Minimum Data Set (MDS) assessment dated [DATE] for Resident #17 shown diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS identified Resident #17 scored a 9 out of 15 on the Brief Interview for Mental Status (BIMS), indicating the resident with severe cognitive impairments. The MDS documented the resident needed extensive of two staff for transfers, bed mobility, toileting and personal hygiene. Review of the Medication Error Report dated 10/25/22 revealed Resident #17 received an extra dose of [MEDICATION(S)] 5 milligram (mg)/325 mg (narcotic pain medication). Review of the Controlled Substance Shift Count and Usage Record revealed a discrepancy on 11/1/22 of a missing [MEDICATION(S)] on 11/1/22. Review of Resident #17's Progress Notes failed to indicate the Power of Attorney (POA) notified of the medication error or the missing medication. During an interview on 11/9/22 at 10:56 AM, Resident #17's POA stated he was never notified from the facility of the medication error or the missing medication. He states the communication with the facility has been poor. During an interview on 11/10/22 at 10:58 PM, the Director of Nursing (DON) stated she was unable to find documentation of the family notification of the medication error or the missing medication. She would expect staff to notify the family of medication errors and missing medications at the time of the incident. The facility provided a policy titled Notification, Resident Representative effective 10/10/19 and the policy stated the resident's representative shall be notified of any accident, injury, or adverse change in a resident's condition requiring physician notification. The procedure directed staff to notify the resident's representative of any accident or unusual incident, regardless of injury.

Based on clinical record review, facility policy review and staff interview the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility reported a census of 30 residents. Findings Include: According to the Minimum Data Set (MDS) assessment dated [DATE] for Resident #17 shown diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS documented Resident #17 scored a 9 out of 15 on the Brief Interview for Mental Status (BIMS), indicating the resident had severe cognitive impairments. The MDS indicated the resident needed extensive of two staff for transfers, bed mobility, toileting and personal hygiene. The Medication Record for October 2022 revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Controlled Substance Shift Count and Usage Record revealed the [MEDICATION(S)] 5 mg/325 mg was signed out four times on 10/25/22. The Medication Error Report dated 10/25/22 revealed Resident #17 received two doses of the [MEDICATION(S)] 5 mg/325 mg within one and a half hour of the previous dose. Staff failed to sign out the medication on the Electronic Medication Administration Record (EMAR) and another staff administered the medication a second time. During an interview on 11/09/22 at 4:27 PM regarding the medication error for Resident #17 on 10/25/22 Staff L, Registered Nurse (RN) stated the medication was not signed out on the EMAR so he thought he needed to administer the medication. He was confused by the Narcotic Count Sheet Record due to the lines above were crossed off and error was wrote next to them. He notified the Director of Nursing (DON) of the Narcotic Record not being accurate via phone. During an interview on 11/10/22 at 12:58 PM, the DON stated on 10/25/22, Staff L notified her the Narcotic Count was off but he did not realize the other nurse working had already given a dose. The nurse did not communicate it to him or sign off on the EMAR she had administered the medication. The DON acknowledged the Narcotic Sheet should have been looked at with the medication error on 10/25/22. She filled out the Medication Error Report the next day after the medication error occurred. The DON stated the expectation is when the Nurse gives a narcotic medication it should be signed off immediately in the EMAR and on the Narcotic Sheet. The facility provided a policy titled Incident Report, Completion with a revision date of 10/24/22 which directed staff an Incident Report shall be initiated for any unusual incidents involving residents whether they occur at the facility or not, whether injury is apparent or not. The policy lists unusual incidents to include medication errors. The policy directed staff to complete the Incident Report Form at the time of the incident. The nurse in charge at the time of the incident shall prepare an sign the report. All blanks shall completed on the Incident Report Form.

Based on observation, clinical record review, staff interview, and facility policy review the facility failed to maintain infection control practices while caring for a catheter for 1 out of 2 residents reviewed (Resident #77). The facility reported a census of 30 residents. Findings Include: The Admission Record for Resident #77 dated 11/10/22, listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/10/22 8:11 AM, Resident #77 in his bed with the catheter drainage bag hung on the left side of the bed. On 11/10/22 at 8:18 AM, Staff A, Certified Nurses Aid (CNA) set the graduated cylinder directly on the floor and drained the Foley catheter bag. Staff failed to place a barrier under the graduate. Staff A re-clamped the drain port, and put the port back in the holder failing to use an alcohol swab to clean the drainage port. Staff A then unhooked the catheter drainage bag from the catheter tubing and attached a leg bag, failing to use an alcohol swab to the end of the catheter before connecting to the drainage bag. On 11/10/22 at 9:21 AM, the Infection Preventionist (IP)/ Assistant Director of Nursing (ADON), said her expectation is the CNA staff use a barrier under the graduated cylinder when a catheter bag is emptied. She stated also expected CNA staff to use an alcohol swab to clean the tip of the drainage tube of the catheter bag after they empty the urine from the bag before they put it back in the holder. The ADON reported her expectation is the staff clean the end of catheter tubing with an alcohol swab after unhooking it from the drainage bag and before they hook it up to the leg bag. The facility provided a policy titled Emptying Catheter Bag dated 10/10/19, it directed use a plastic bag under the graduate on the floor. The policy continued to direct use an alcohol pad to clean the tip of the tubing, open clamp and drain the urine into graduate, close the clamp and wipe tip again with a clean alcohol wipe.

Based on record review, staff interview and Facility Matrix Form review, the facility failed to adequately inform residents of their right to appeal a decision for discontinuation of Skilled Services for 1 out of 1 residents remaining in the facility (Resident #17). The facility reported a census of 30 residents. Findings Include: Record review of Resident #17 shown the resident discharged from Medicare Skilled Care Services to Nursing Facility Level of Care on 10/26/22. Review of the Center for Medicare Services (CMS) Form - , Notice of Medicare Non Coverage (NOMNC)) provided to the resident representative by phone on 10/26/22 failed to have form CMS- , Skilled Nursing Facility Advanced Beneficiary Notice (ABN), which explains the options a resident can chose and signed by the resident During an interview on 11/10/22 at 8:43 AM, the Social Worker (SW) stated she was responsible for providing the NOMNC Form to resident representatives and just learned about the ABN this week. The SW stated she learned there is another form when they switch to private pay you need to provide to the resident, resident representative or the Power of Attorney (POA), which is the ABN. The SW reported unaware of the need to give the second form. During an interview on 11/10/22 at 1:43 PM, the Administrator stated the Social Worker was responsible for completing the ABN. The Administrator stated she expected the SW to complete the ABN Form on time and by the timeliness and requirements of the regulations. The facility provided an Beneficiary Notice Matrix 2020 and it directed staff to provide the CMS- (ABN) form if the resident will remain in the facility.

Based on observations, staff interviews, and record review the facility failed to properly cover clean laundry carts in an effort to reduce the risk of spreading infections. The facility reported a census of 19 residents. Finding Includes: Observation on 6/2/21 at 8:40 AM, revealed Staff A, Environmental Services, passed personal laundry to several resident rooms in an uncovered wire cart. The laundry is stored individually in mesh bags but not covered. During the Laundry Tour on 6/2/21 at 1:45 PM, Staff A presented a clean linen cart with a see through mesh cover used during the transportation of clean linens. During an interview with Staff A on 6/2/21 at 8:40 AM, confirmed that when she passed the clean linen cart it was always covered but when passing the clean personal laundry it was not covered but delivered in mesh bags specific to each resident. The mesh holes were the size of a pencil eraser throughout the bags. During an additional interview and tour of the laundry room on 6/2/21 at 1:45 PM, Staff A stated that the clean linen cart had a mesh netting to cover linens during transport and the resident's cleaned personal clothing transported in an uncovered wire cart in individual mesh bags. During an interview on 6/2/21 at 2:18 PM, the Director of Nursing (DON)/Infection Preventionist stated her expectation that the linen cart be covered when laundry transported to the rooms. The cart covering protects clothes from any one touching them and from airborne contaminants. The Infection Prevention and Control- Laundry policy dated 8/1/17 documented the facility shall employ a common sense hygienic practice for the processing and storage of linens. Clean linen shall be handled, transported, and stored by methods that will ensure its cleanliness.

Based on record review, observation and staff interviews, the facility filed to follow Physician's orders for 1 out of 5 Residents reviewed (Resident # 66). The facility reported a census of 19 residents. Findings included: Review of the Admission Record for Resident #66, dated 6/2/2021, listed principal diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Emergency Department Transfer orders for Resident #66 dated 5/30/21, directed Nursing Staff to administer [MEDICATION(S)] (antibiotic) 500 milligrams (mg) by mouth every 6 hours for 10 days for a urinary tract infection (UTI). The Baseline Care Plan for Resident #66 dated 5/30/21, directed [MEDICATION(S)] 500 mg every 6 hours for 10 days for a UTI. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 6/2/21 7:47 AM, noted Resident #66 up walking with 2 staff in the hallway. Interview on 6/2/2021 at 1:18 PM, Staff B, Registered Nurse (RN) verified the MAR for Resident #66 lacked an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 6/2/21 at 1:33 PM, the Director of Nursing (DON) reported Resident #66 at the facility for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] On 6/2/21 at 1:35 PM, the DON reported she reviewed the Current Admission Medication list for Resident #66 and failed to see the [MEDICATION(S)] order. Interview on 6/2/21 at 2:12 PM, the DON confirmed a medication error occurred. The facility provided a policy titled Physician Visits and Medical Orders dated 5/10/17. The policy directed on page 2 Members of the interdisciplinary team shall provide care, services and treatment according to the most recent medical orders and according to laws, regulation and standards practice.

Based on record review and staff interview the facility failed to ensure compliance with Medicare regulations for two out of three residents reviewed (Resident #118 and #120) receiving skilled care services and were discharged . The facility reported a census of 19. Findings include: 1. Record review of Resident #118 shown the resident discharged from Medicare Skilled Care Services to Nursing Facility Level of Care on 3/31/21. Form Center for Medicare Services (CMS) - NOMNC (Notice of Medicare Non Coverage) signed and dated 3/29/21 by resident #118. The facility failed to have form CMS- Skilled Nursing Facility Advanced Beneficiary Notice (ABN), which explains the options a resident can chose, signed by the resident 2. Record review of Resident #120 shown the resident discharged from Medicare Skilled Care Services to Nursing Facility Level of Care on 12/10/20. The Medicare form CMS - NOMNC provided with date of 12/10/20 and noted signed by the resident, but not dated. During an interview on 6/2/21 at 11:29 AM, the Administrator stated she failed to get the ABN form for Resident #120 who discharged from Skilled Care Services to Private Pay Services. The Administrator explained there was a discussion and the resident knew he was going private pay but she failed to complete the form. During an interview on 6/02/21 at 12:30 PM, the Administrator stated they infrequently have residents who stay for long term care and not aware of the regulation for the second notice. They are constantly talking about discharge plans and feel the residents are aware of status, but she did not know of the regulation to give the CMS- (ABN) form to the resident if they chose to stay long term at the facility. The facility provided an Beneficiary Notice Matrix 2020 and it directed staff to provide the CMS- (ABN) form if the resident will remain in the facility.

Based on observation, staff record review and staff interviews, the facility failed to ensure the Dietary Manager completed the required education in a timely manor. The facility reported a census of 19 residents. Findings included: Observation on 6/02/21 at 11:52 AM, the Dietary Manager (DM) served the noon meal trays. Review of the Personal Record dated 10/18/18 identified Staff C's job title as Supervisor. The Local Collage Continuing Education form dated 1/10/2019, revealed Staff C registered for 90 Hours Food Service course to start on 3/25/2019 and end 10/15/2019. Review of the Performance Evaluation Review dated 5/14/19, identified Staff C, Dietary Supervisor, included a goal for Staff C to complete the Certified Dietary Manager (CDM) training by 8/2019. Interview on 6/01/21 at 10:27 AM, Staff C reported her job title is DM. Staff C revealed she failed to complete the necessary training. Interview on 6/02/21 at 3:42 PM, the Administrator confirmed Staff C failed to complete the 90 Hours Food Service course requirement to be a CDM. Review of the Food Service Supervisor Job Description dated 1/2019, directed the Supervisor must have a Food Protection Manager Certification as well as be a Certified Dietary Manager.

Based on record review and staff interview, the facility failed to document that a standardized assessment data form had been sent with a resident transferred to a hospital for one of two residents reviewed in the standard sample (Resident #72). The facility reported a census of 22 residents. Findings include: Resident #72's Minimum Data Set admission assessment completed 6/5/19 had documentation of the following Diagnoses: [REDACTED]. It also identified the resident as cognitively intact with a BIMS (brief interview for mental status) score of 15 out of 15, required extensive staff assist with most activities of daily living, not steady with balance and required staff assistance with moving from seated to standing position, moving on and off the toilet, surface to surface transfer, had an impairment to one leg and utilized a wheeled walker and wheelchair for mobility devices. A review of the Nurse's Notes for Resident #72 shown the following documentation: On 6/18/19 at 8:06 a.m., leaving at this time for a scheduled surgery at the hospital. Medications given this morning per orders, walker, [MEDICAL CONDITION] (continuous positive airway pressure) machine and glasses sent with resident. The chart did not contain documentation to indicate the transfer form sent with the resident as he went to the hospital. During an interview on 7/17/19 at 10:00 a.m., Staff D, Registered Nurse (RN), reported when a resident is transferred to the hospital for a planned surgery, the nurse needs to complete a transfer/discharge form which should be sent with the resident and charted in the nurse's notes. In an interview on 7/17/19 at 12:00 p.m., the Director of Nursing (DON) reported the facility did not have a policy related to transfers of residents to a hospital and provided paperwork which the hospital had sent as being received and only the residents IPOST (Iowa Physician order [REDACTED]. During an interview on 7/18/19 at 7:00 a.m., the DON reported if a resident is transferred to the hospital for surgery, she would expect the nurse to send a transfer form, IPOST and their surgical folder (which comes from the surgeon's office). The office will call and ask for information about the resident such as medication list, history, demographics, anything they would need to know about the patient that is then entered into the computerized record at the hospital. She would expect her staff to chart that the resident left the building and what articles accompanied them.

Based on clinical record review and staff interview, the facility failed to provide notice to the resident and/or resident representative of the facility's Bed Hold Policy prior to or upon transfer to the hospital for 1 of 3 residents reviewed (resident # 18). The facility reported a census of 22 residents at the time of the survey. Findings include: 1. Review of Resident #18's medical record revealed no documentation of notification to the resident or resident's family regarding the bed hold policy when the resident transferred to the hospital on [DATE] and returned on 6/3/19. Clinical record review of Census List revealed resident #18 transfer out to the hospital on [DATE] and returned on 6/3/19. Review of the facility Bed Hold Policy dated 1/31/17 revealed the following procedure: 1. Before a resident is transferred to a hospital or the resident goes on a therapeutic leave, the facility will provide the bed hold notice form to the resident or resident's representative. a. The bed hold notice will be printed on the facility's letterhead thus identifying the facility and providing contract information. b. A facility representative will note the resident or resident representative's decision to hold the bed as either an Administrative Note or a Clinical Progress Note. The note will include the person making the decision, the decision to hold or not hold the bed, and the time frame for holding the bed. During an interview on 7/16/19 at 4:05 p.m., the Director of Nursing (DON) acknowledged the lack of documentation regarding resident #18. The DON stated the expectations are for nursing staff to document that the bed hold policy be explained to the resident or family member when a resident is discharged to the hospital.

Based on observation, facility policy review and staff interview, the facility failed to maintain infection control practices during distribution of clean laundry on 2 of 2 floors in the facility. The facility census was 45 residents. Findings include: 1. During observation on 4/23/18 at 3:00 p.m., Staff A, Laundry Aide pushed an uncovered laundry cart off the elevator onto the 2nd floor and delivered clothing down the hall to resident rooms. At 3:04 p.m., Staff A removed hanging clothes from the uncovered clean laundry cart and carried them into the last room on the left (242). Staff A went right across the hall with clothes on hangers and delivered them to room [ROOM NUMBER]. At 3:08 p.m., Staff A removed clothes from the uncovered clean hanging laundry cart as a resident stood next to the uncovered clean laundry cart. At 3:09 p.m., Staff A took clothes to room [ROOM NUMBER] leaving the uncovered clean laundry cart by 3 wandering residents in the hall on the 2nd floor. At 3:10 p.m., Staff A took clothes to room [ROOM NUMBER]. At 3:11 p.m. Staff A pushed the uncovered laundry cart onto the elevators. 2. During observation on 4/25/18 at 2:15 p.m., Staff A came out of the service hall on the 1st floor with an uncovered full cart of hanging laundry. Staff A took the uncovered clean laundry cart down the 1st floor and delivered clothes to resident rooms. At 2:20 - 2:27 p.m., Staff A pushed the uncovered laundry cart to the east end of the 1st floor delivering clothes. At 2:27 p.m., Staff A pushed the uncovered clean laundry cart into the elevator to get to the 2nd floor. During observation on 4/25/18 at 2:32 p.m., Resident #30 was pushing the uncovered laundry cart and clean clothes down the hall as Staff A was in a resident room. At 2:37 p.m., Staff A removed clothes from the clean laundry cart and walked to the last room to deliver leaving the cart uncovered. At 2:39 p.m., Staff A pushed uncovered laundry cart back on elevator. At 2:42 p.m., Staff A delivering clothes to rooms on the west end of the 1st floor. During interview on 4/25/18 at 2:57 p.m., Staff A stated the clean underclothes on the white cart with a pink cover in the corner go out for delivery at 5:30 p.m. Staff A stated we have to have the pink cover over the socks and under clothes, not sure why no cover on the hanging laundry cart. Sometimes residents will come up to the cart to get their clothes. Staff A reported the delivery procedure was always that way. During interview on 4/25/18 at 3:33 p.m., Staff C, Infection Control Nurse stated not knowing the procedure for delivering clothes. Staff C reported the underclothes are covered during delivery and the hanging clothes are not. Staff C confirmed not knowing why one is covered and the other is not. Staff C continued to report the expectation for handling clean clothing is too maintain infection control practices. Staff C stated taking clean clothing in one resident's room and then going across the hall to put the cloths away in another residents room is not an acceptable practice. The facility provided a policy titled Infection Prevention and Control Laundry dated 2/18/18, directing staff clean linen shall be handled, transported and stored by methods that will ensure its cleanliness.